What ails our health and education system?

I have read or seen any number of articles and TV discussions, wailing and complaining about how the bureaucratic and political system in India has messed up, among other things, our health care and education. It is a common refrain that though we have excellent policies and programs, our bureaucracy and politicians fail us in implementation. Interestingly, even I used to believe in the same diagnosis till I became a bureaucrat myself. With an insider's perspective, now I have a different opinion on the issue. No, there is no vested interest here, but an attempt at a honest introspection.

I will try to illustrate my case with an example. The Integrated tribal Development Agency (ITDA) of Bhadrachalam is spread out over 12175 sqkm, and has a population of over 8 lakhs. There are about 847 schools, with nearly 5000 teachers, and 70000 children in 2006-07. Among these 847 schools, 645 are elementary and often single or two teacher schools, scattered across the villages in the tribal area. The health logistics is equally massive. There are 49 Primary Health Centers, over 300 sub centers, 10 Government hospitals, and 2 Tertiary Care Hospitals. These hospitals employ over 75 doctors, 350 nurses and other paramedical staff, and 2189 Community Health Centers (CHWs). This is a more or less representative sample of education and health infrastructure in rural India.

Now, I will stick out my neck and argue that no amount of regulation and supervision alone, will abe able to control the activities of nearly 3000 health and over 5000 education staff, spread over the 12175 sq km area of Bhadrachalam. This requires calling on the inherent strength, capacity, and discipline within the entire system and its functionaries. It also requires vibrant demand side interventions and vigilance.

What are the typical problems observed in health care and education? Infrastructure and logistics are rarely the problem, though a lot more still remains to be done on that front. But the major issue is at the cutting edge, in the physical delivery of these services. To be more specific, I am referring to the quality of teaching and health care services delivered to the students and the patients by the education and health functionaries. This quality is abysmal and universally so, in all its dimensions.

For a start, a good majority of teachers and health staff do not regularly attend to their duties. Even when they do, they often shirk repsonsibility and the quality of service delivered suffers. Further, for various reasons, teachers and medical staff are poorly trained and even more poorly motivated. Many of the schools and health sub-centers are located in remote areas with poor or even non-existent roads, which are often inaccessible by any mode of public transport. There are limited or no proper accommodation facilities available, so that the teachers stay elsewhere and have to commute long distances daily. This is an immediate incentive for not attending school or hospital under some pretext or the other. Further, houses and habitations are scattered and in the absence of connectivity, it becomes difficult to traverse without personal vehicles.

On the demand side, with the domestic economic and social compulsions, children frequently drop out and back in, and it becomes a serious challenge to retain children in schools. In many villages, there is no serious demand side pressure and a lack of manifest collective will in ensuring that the school is run properly. Even if the collective will is present, the community is often powerless to have its own way. School and Hospital Committees, wherever present become ornamental and get captured by vested interests.

There are no simple solutions for these very diverse and challenging problems. No Government machinery or political and bureaucratic system can wave a magic wand to solve them. No regulatory or bureaucratic solution can get teachers to visit school everyday or pay attention to the progress of each child. Neither can it get para-medical staff to cover every child and mother with all basic RCH care, or follow-up on all malaria and TB patients without any omission.

While the regulatory and supervisory mechanism is undoubtedly important, of more relevance is the inherent capacity, responsiveness, sense of civic duty and discipline, within the system and its stakeholders. The initiative and responsiveness of the teacher or the paramedical staff is the crucial determinant in the quality of service delivered in an elementary school or health sub-center. No amount of monitoring and supervision, regulation, review meetings and reporting formats, can be a replacement for the sincerity and committment of a field functionary. We need to build capacity among field functionaries through continuous, more focused and meaningful trainings, significantly raise motivation levels, and foster competition and commitment within them. There is also the need to develop social capital and civic responsiveness among the local community and citizens.

Amidst all this gloom and adversity, and the challenges posed by scarce resources, there are glowing examples of well run schools and health centers. These schools are shining models because of the exceptional personal commitment and initiative of the respective teachers and the civic responsiveness of the local community. For these teachers, each child is not a mere statistic, but an opportunity to shape the future of a child whose fate has been placed at their hands. Similarly, there are para-medical staff who cover every ante-natal and post natal case within their jurisdiction, and who have achieved substantial success in delivering high quality RCH and general primary health services. These successes, in the sea of failures and poor quality service delivery, are testimony to the commitment and initiative of the field functionaries and the community.

Now, many people will claim that things are changing and demand side repsonsiveness, in particular, has become more robust. True, but not in the scale for it to create a substantial and widely felt impact. Typically, aid agencies and opinion makers are exposed only to the successfully run school or hospital systems, where there is harmonious convergence between the functionaries and the community. It is understandable, but misleading to draw grand conclusions from these "show piece" models.

With due respect to poverty experts, I am convinced (since I am part of the system which does this) that except for a very small minority, the majority of them are paraded or get to visit only the more sanitised and successfully run models. This is understandable since the NGOs or the Government agencies have a clear incentive in showcasing the successes, so as to impress the funding agencies or donors, and also to enhance their reputations. The impressions they carry back home and propagate are therefore skewed and deceptive.

Yes, bureaucrats and politicians have contributed more than their share in spoiling the quality of primary health care and education services delivered by the Government. But blaming them for all the malaise is a gross simplification of the reality. The diagnosis lies elsewhere, and the prescription is not very easy to implement.